Hemostatic implant introducer

ABSTRACT

A puncture seal device for stemming the flow of blood from a punctured blood vessel has an elongated outer sheath affixed to a generally tubular housing where the housing contains a manually actuable slide which is affixed to a rigid tubular pusher member coaxially disposed within the outer sheath. Also contained within the outer sheath in longitudinal alignment with the pusher and distally thereof is a ring-shaped plug of a hemostatic material. The assembly thus far described may be fitted over a tubular introducer or the body of a catheter and then advanced therealong until the distal end of the outer sheath is proximate a bleeding blood vessel. By actuating the pusher member, the hemostatic plug surrounding the introducer or catheter is ejected from the distal end of the outer sheath and held in abutting relationship to the bleeding blood vessel.

CROSS-REFERENCE TO RELATED APPLICATION

This application is a continuation-in-part application Ser. No.07/784,920, filed Oct. 30, 1991, and entitled "HEMOSTATIC IMPLANTINTRODUCER".

BACKGROUND OF THE INVENTION

I. Field of the Invention

This invention relates generally to a surgical instrument for use inintravascular catheterization procedures, and more particularly todevices for positioning a hemostatic agent against a puncture entrywound in a blood vessel to stem the flow of blood therefrom followingremoval of the catheter and catheter introducer at the conclusion of theprocedure.

II. Discussion of the Prior Art

When performing angiography or angioplasty procedures, following theSeldinger technique, the angiography catheter or angioplasty catheter isgenerally introduced into the vascular system by first employing asharpened hollow needle to penetrate the skin, the underlying muscletissue, and to enter the selected blood vessel. Next, a guidewire iscommonly inserted through the lumen of the hollow needle and made toenter the selected blood vessel. Following that, the needle is strippedoff the guidewire and a combination of a dilator and an introducer (oran introducer alone) are fed over the guidewire and pushed through theskin until first the dilator and next the introducer enter the selectedblood vessel. The guidewire may next be removed, and the selectedcatheter for carrying out the procedure is fed through the lumen of theintroducer and advanced through the vascular system until the workingend of the catheter is appropriately positioned. Depending upon theprocedure, a dye may be injected through the catheter or a balloonexpanded. Following the conclusion of the catheterization procedure, theworking catheter will be withdrawn and, subsequently, the combinationdilator and introducer will also be stripped out of the wound.

Because it is common practice to administer a blood thinning agent tothe patient prior to many of the procedures, a problem exists instemming the flow of blood through the puncture wound made in the veinor artery. Typically, it is necessary to maintain pressure over theregion for at least 30 minutes. Even more time is required if thepatient is hypertensive or anticoagulated. When human hand pressure isutilized, it is somewhat wasteful of professional time. Devices, such aspressure bandages, sand bags or clamps may be employed, but for thesedevices to work, the patient must be compliant and motionless for thisprolonged period. Also, with obese patients, because of the significantamount of tissue between the skin and the penetrated vessel, goodhemostatic pressure oftentimes cannot be obtained above the penetratedartery or vein. Thus, a need exists for a means for acceleratinghemostasis.

In U.S. Pat. Nos. 4,852,568 and 4,890,612 to Kenneth Kensey, a deviceand method is described for sealing puncture or incision wounds createdpercutaneously during a surgical procedure. In accordance with theteachings of the Kensey patents, a collagen plug having an anchoringmechanism in the form of a filament or string attached, is passedthrough the introducer following removal of the working catheter and isallowed to enter the blood vessel to be sealed. The introducer is thenremoved from the body and the string is tensioned until the collagenplug affixed to its end abuts the surgically-created opening in theblood vessel proximate its interior wall. When the collagen material isexposed to body fluids, it swells to create a block for the wound in thevessel wall while the collagen itself acts as a blood clotting agent andaccelerates hemostasis.

Problems exist with the approach set out in the aforereferenced Kenseypatents. More particularly, any intraluminal deposition of a collagencan result in embolization, especially as the material begins toreabsorb. Particles may break off and float downstream to the pointwhere they may lodge in a smaller vessel, causing an infarct to occur.Not only that, but collagen material acts as a nidus for plateletaggregation which assists in blood clotting. Hence, the intraluminaldeposition of a hemostatic agent can initiate a thrombosis at the site.

U.S. Pat. Nos. 4,838,280 and 4,936,835 to John R. Haaga teach the ideaof incorporating a hemostatic material as a part of a needle biopsydevice so that following the gathering of the tissue sample, ahemostatic plug can be left in the void in the tissue from which thesample had been excised. The collagen plug that is left behind serves asa hemostatic agent for more rapidly stemming blood flow from the pointof injection of the biopsy needle.

Applicants are also aware of a product produced by Datascope Inc. ofMontvale, N.J., and sold under the trademark "VASOSEAL". That devicecomprises a kit including a guidewire, a needle clip, a skin dilator, anouter syringe barrel, an inner plunger, and two cylinders of compressedcollagen material. In carrying out the blood vessel sealing procedureusing the VASOSEAL apparatus, two operators are required. Before theoriginal puncture needle is removed, a clip is placed on the shaft ofthe needle at the skin level to mark the distance down to the artery.The needle and clip are then placed up against a card having graduationsprinted thereon and one of a plurality of device lengths are selected.When the catheterization procedure is completed, all devices are removedexcept for a guidewire. One operator is needed to maintain compressionupstream while another operator works on the puncture site. A skindilator is advanced over the guidewire into the tissue to the measuredlevel. A syringe barrel is then advanced over the skin dilator to thesame measured level. The dilator and the guidewire are then removed.Next, a plunger is loaded with one of the two plugs of collagen and thisis inserted into the syringe barrel and advanced down into the wound.The plunger is removed and reloaded with a second collagen plug andthis, too, is inserted down into the syringe barrel into the wound. Themain operator now takes over the job of applying a compression forceover the area and holds the spot for several minutes. When no bleed-backor hematoma growth is seen, the operator removes the syringe andplunger.

OBJECTS

It is accordingly a principal object of the present invention to providean improved method and apparatus for effecting hemostasis in the courseof a surgical procedure.

Another object of the invention is to provide an improved method andapparatus for plugging a surgically-created puncture in a blood vessel.

Yet another object of the invention is to provide an improved apparatusfor deploying a hemostatic material against the exterior surface of ablood vessel at the point of a puncture opening therein.

Yet another object of the invention is to provide an apparatus forselectively displacing a coaxially mounted mass of a hemostatic materialfrom a position in surrounding relationship relative to a tubularinstrument that has been inserted through the puncture so that the massassumes a position in abutting relationship relative to a puncture siteon the exterior wall of a blood vessel.

Still another object of the invention is to provide a method andapparatus for effecting hemostasis of a puncture wound in a blood vesselin which a mass of a hemostatic material coaxially surrounding a tubularmember is made to abut a puncture site in a blood vessel, but withoutany of the hemostatic material entering the lumen of the blood vesselnor without the need for an anchoring mechanism.

A still further object of the invention is to provide a surgicalinstrument for use during a catheterization procedure, a laparoscopicprocedure or any other endoscopic procedure for installing a plug of ahemostatic material in abutting relation to the exterior wall of a bloodvessel at a site where that blood vessel has been penetrated, the devicebeing unobtrusive and easy to utilize by a single operator.

SUMMARY OF THE INVENTION

The foregoing features, objects and advantages of the invention areachieved by providing a first tubular member, which is adapted to beinserted into a surgically-created opening in a blood vessel, with amass of a hemostatic material configured to coaxially surround theexterior of that tubular member. The term "tubular member", as used inthis context, is intended to broadly describe any one of a dilator, anintroducer, or a catheter. Coaxially surrounding the first tubularmember with a predetermined clearance and shielding the plug fromexposure to body fluids, principally blood, is an outer tubular sheathhaving a proximal end, a distal end, and a lumen extending therebetween.A means for ejecting the hemostatic mass in the form of a tubular pusheralso surrounds the first tubular member and is contained within thelumen of the outer tubular sheath. A housing is affixed to the proximalend of the outer sheath and a slide, coupled to the pusher, is containedin the housing. In one embodiment, a protruding thumb pad is providedfor applying a moving force to the slide. In another, a rack and pinionmechanism is employed to move the pusher relative to the hemostaticmass. By advancing the pusher in the distal direction, its distal endengages the coaxial disposed hemostatic mass and is used to force itoutward of the lumen of the tubular sheath member so that it will abutthe penetration site in the wall of the blood vessel.

In a modified arrangement, the hemostatic mass is annular in shape andis housed within an outer tubular sheath proximate the distal end of thesheath. The pusher is also tubular and has its distal end abutting theproximal end surface of the hemostatic mass within the outer sheath. Theproximal end of the pusher extends beyond the proximal end of the outersheath. In use, the instrument is threaded over the tubular member andits distal end is made to abut the exterior wall of the punctured bloodvessel. To deploy the hemostatic mass, the pusher is held stationarywhile the outer sheath is pulled rearward, uncovering the mass. Then,the entire instrument can be stripped back off of the tubular member. Toavoid accidental, premature ejection of the hemostatic mass, a suitablelocking arrangement is used to couple the pusher to the outer sheath toprevent relative movement between these two parts until the lock isreleased.

In accordance with a further modified embodiment, the coaxially disposedmass, as well as the tubular sheath, the tubular pusher and the housingsupporting the sheath and pusher are longitudinally slit to allow theunit to be assembled onto the exterior of a tubular body from the siderather than using a coaxial approach.

The hemostatic mass may comprise a freeze-dried collagen, a cellulosegel material, such as a GELFOAM®, a resorbable lactide/glycoside orother resorbable substance which by virtue of its chemical properties orits lattice construction functions as a hemostatic agent. It ispreformed so as to fit within the confines of the tubular sheath memberin surrounding or coaxial relationship to the first tubular member, butwhen deployed out through the distal end of the outer sheath member,will expand when contacting body fluids to form a predetermined shapeconfiguration. The annular collagen plug is preferably a composite whichis preformed to exhibit a distal, vessel puncture-contacting end that ishighly hemostatic and a proximal region that is highly self-expanding.When released from the confines of the puncture sealing device (PSD), itswells to block the wound and to maintain itself in position.

DESCRIPTION OF THE DRAWINGS

A better understanding of the invention will be had by a reading of thefollowing detailed description of the preferred embodiment, especiallywhen considered in conjunction with the accompanying drawings in whichlike numerals in the several views refer to corresponding parts.

FIG. 1 is a longitudinal cross-sectional view illustrating theconstruction of a first preferred embodiment of a puncture sealingdevice;

FIG. 2 is an enlarged, partial view of the distal end portion of thepuncture sealing device of FIG. 1.;

FIGS. 3A, 3B and 3C are enlarged, partial cross-sectional views of thedistal end portion of the puncture sealing device having modified sheathconfigurations;

FIG. 4 is a bottom view of the puncture sealing device of FIG. 1, butmodified in accordance with a second embodiment;

FIG. 5 is a perspective view of a hemostatic mass to be used with theembodiment of FIG. 4;

FIG. 6 is a side sectional view of the puncture sealing device inaccordance with a third embodiment;

FIG. 7 is a side sectional view of the puncture sealing device inaccordance with a fourth embodiment;

FIGS. 8A, 8B and 8C are perspective views of the device of the presentinvention helpful in understanding the method of use thereof;

FIG. 9 is an enlarged view of an alternative design for a puncturesealing device in accordance with the invention; and

FIG. 10 is an enlarged view of yet another alternative design for apuncture sealing device in accordance with the invention.

DESCRIPTION OF THE PREFERRED EMBODIMENT

In describing the construction and mode of operation of the presentinvention, it will be considered as being used in connection with theconduct of the Seldinger procedure for introducing a catheter into thelumen of a blood vessel. It is to be understood, however, that theinvention may also be utilized in other surgical procedures, such aslaparoscopic or other endoscopic procedures, wherein a tubular workinginstrument is routed through the lumen of a tube and where penetrationof a blood vessel, such as a vein or artery, is likely to beencountered. Having described the present invention in connection withthe Seldinger procedure, those skilled in the art will readilyappreciate how the device and method may be employed in other relatedprocedures.

Referring now to FIG. 1, there is shown a perspective view of thepuncture sealing device (PSD) in accordance with a first embodiment ofthe present invention deployed on the conventional apparatus used inintroducing a working catheter into the lumen of a blood vessel, such asthe femoral artery. More particularly, as those skilled in the artappreciate, a hollow needle (not shown) having a sharpened distal endand graduated markings along its length is first pushed through thedermal layer and is made to enter the lumen of the femoral arterythrough a puncture wound created by the needle in the wall of thatartery. The depth of the artery can be assessed by noting the markingson the needle at the point where blood is first exiting the needle.Next, a guidewire, identified by numeral 10, is inserted through thehollow needle into the artery and advanced a predetermined distancetherein. The hollow needle is then stripped off the proximal end of theguidewire 10, and a dilator 12 may then slipped therealong in the distaldirection until its tapered distal end 14 is made to enter the wound,enlarging it to the point where the distal end 16 of a tubularintroducer 18 may also be made to enter the lumen of the selected bloodvessel without creating a tear.

The stepped junctions between the guidewire and the distal end of thedilator and between the dilator and the distal end of the introducer,upon entering the opening in the blood vessel creates a noticeabletactile response to the operator. For reasons which will become moreapparent when the method of operation is discussed, instead of havinggraduated markings on the puncture needle, the dilator 12 may havegraduated measurements or markings on the exterior thereof as identifiedby numeral 15 in FIG. 1. When the distal end 14 of the dilator 12 entersthe blood vessel, the tactile indication provided to the surgeon alertshim or her to glance at the portion of the dilator exposed above theskin to obtain a coarse estimate as to the distance beneath the skin atwhich the opening in the blood vessel is located.

Referring still to FIG. 1 and the longitudinal cross-sectional view ofFIG. 2, the proximal end 13 of the dilator 12 has a molded plastic hub20 affixed thereto, the hub having a tapered distal nose portion 22thereon. A longitudinal bore 24 extends through the hub to allow theguidewire 10 to pass. Likewise, the proximal end 17 of the tubularintroducer 18 is secured within a socket formed in a molded plastic hubmember 26. The hub has a tapered bore 28 in its proximal end forreceiving the tapered nose 22 of the dilator, thus allowing the twoparts to be releasably locked or joined relative to one another. Thoseskilled in the art will also appreciate that other known lockingmechanisms can be incorporated on the PSD for releasably clamping thatdevice to the tubular support (introducer or catheter) which the PSDsurrounds. For example, the commonly used Touhy Borst clamp may beconfigured on the proximal end 34 of the PSD whereby simple rotation ofa knob will lock or unlock the PSD to the tubular body 12 depending onthe direction of rotation.

As can be seen from FIGS. 1 and 2, the guidewire 10, dilator 12 andintroducer 18 are coaxially disposed relative to one another and extendthrough a housing member 30 which forms a part of the PSD indicatedgenerally by numeral 32. The housing 30 has a proximal end 34 having anopening formed therethrough for receiving the tubular introducer 18.Also forming a part of the housing is a distal end cap 36. The tubularsheath or barrel member 40, like the dilator 12, is provided withgraduated markings, as at 41, which permit the surgeon to insert thedistal end of the sheath to a premeasured depth below the skin. As shownin FIG. 2, the proximal end 38 of a tubular sheath member 40 is fittedinto the end cap 36 and is adhesively bonded or otherwise fixedlyattached to the end cap 36. The inside diameter of the plastic sheath 40is sized to provide a predetermined clearance between it and the outersurface of the introducer 18.

Contained within this clearance space and proximate the distal end 42 ofthe sheath 40 are one or more pieces 44 of a suitable hemostaticmaterial which are preformed to assume a coaxial disposition relative tothe introducer 18 or other "tubular member" as that term was earlierdefined at page 5, supra. The material may be freeze-dried collagen, acellulose gel, a resorbable polyglycolic acid composition or anysuitable resorbable substance which, by virtue of its chemicalcomposition or of its lattice construction, acts as a hemostatic agent.The mass 44 partially or fully surrounds and fits snugly against theouter diameter of the tubular introducer 18, within the confines of thesheath 40 where it remains generally isolated from contact with bloodand other body fluids until deployed. By virtue of being in a compressedstate until deployed, it is prevented from prematurely reacting withblood.

A longitudinal slot 46 is formed through the housing 30 allowing athumb-operated slide assembly 48 to pass therethrough. The slideassembly includes a thumb pad 50 which is attached to a slide member 52contained within the housing 30. The slide 52 includes a bore 54 throughwhich the tubular introducer 18 may pass. The proximal end 56 of agenerally rigid tubular pusher 58 is affixed to the slide 52 and, thus,is movable therewith. The distal end 60 of the tubular pusher is adaptedto engage the proximal edge surface of the coaxially disposed hemostaticmass 44 when the slide is moved in the distal direction (to the right inFIG. 2).

A locking pin is shown as passing transversely through an aperture 62across the slot 46 prevents inadvertent movement of the thumb slideassembly 48 and premature ejection of the hemostatic plug. Alternativelocking arrangements are also envisioned, including placing a downwardlyextending barb or latch on the proximal end of thumb pad 50 whichcooperates with the proximal end 34 of housing 30 to prevent movement ofthe slide until the barb or latch is intentionally released. Thoseskilled in the art will recognize that other "safety" devices can beused to prevent unintended deployment of the hemostatic material fromthe barrel or sheath 40.

As is illustrated in FIGS. 2 and 3A, the distal end portion 42 of theouter tubular sheath 40 may be rounded or bullet-shaped andappropriately slit to more readily permit the coaxial plug(s) 44 to beejected out from the nose 42 of the sheath 40 upon actuation of theslide assembly 48 to which the tubular pusher 58 is affixed. FIGS. 3Band 3C illustrate that the distal end of the tubular sheath 40 may beblunt or beveled and also that the hemostatic material, as at 44, may bepreshaped into a desired configuration, with FIG. 3B showing a somewhatmushroom-shaped arrangement and FIG. 3C showing a beveled shape. Abeveled tip on the distal end of the outer tubular sheath assists incutting its way through the skin and subdural tissue in approaching thepunctured blood vessel.

It is also possible to preform the hemostatic mass in other forms,including, for example, as a helix or a woven or braided structure, theprime requirement being that it can be coaxially disposed about atubular member as previously explained. Upon exposure to body fluidsupon release thereof from the sheath, the mass will swell to define apredetermined shape, e.g., rounded, blunt, frustoconical, beveled ormushroom.

In the arrangement shown in FIGS. 1 and 2, the device for placing theplug of hemostatic material against the exterior wall of a blood vesselat a point of puncture entry must be assembled onto the introducer anddilator before the assembly is threaded onto the guidewire. In thearrangement shown in FIG. 4, the plug placement instrument 32 isdesigned so that it can be placed onto the body of a tubular member at atime just prior to when the surgeon wishes to inject the hemostaticplug. More particularly, FIG. 4 is a bottom view of the instrument,i.e., the side thereof which is opposite to the thumb rest member 50. Itcan be seen that in the embodiment of FIG. 4, a longitudinal slit 64 isformed through the walls of the tubular sheath 40, the tubular pusher58, the housing 30 and the slide 52. Furthermore, as shown in FIG. 5,the hemostatic mass 44 used with the embodiment of FIG. 4 is generallyC-shaped having a slot 66 formed through its wall and communicating withthe central opening 68 thereof. By providing the slots 64 and 66 in therespective pieces mentioned, the device of FIG. 4, loaded with one ormore pieces of preshaped hemostatic material 44, may be assembled onto atubular member such as an introducer, a working catheter used with anendoscope or other similar device by merely slipping it onto the tubularmember from the side with the tubular member fitting into the respectiveslots 64 and 66. This may prove more advantageous than an over-the-wireinstallation of the loaded PSD.

ALTERNATIVE EMBODIMENT

Referring now to FIG. 6, there is shown a further alternative embodimentof a PSD in accordance with the teachings of the present invention. Inthis view, the device is shown in longitudinal cross-section but doesnot include the coaxial arrangement of a guidewire, dilator andintroducer as in the arrangement shown in FIGS. 1 and 2. It is to beunderstood, however, that the device of FIG. 6 is intended to beassembled on to a tubular member, either using an endwise over-the-wireapproach or a side approach as with the earlier described embodiment.The PSD is indicated generally by numeral 70 and is seen to include amolded handle member 72, preferably formed from a medical-grade plastic.The handle 72 includes a longitudinal bore 74 in which is fitted theproximal end of a tubular outer sheath or barrel member 76. Containedwithin the lumen of the sheath 76 near its distal end 78 is a mass ofhemostatic material 80 which is preshaped so that it can assume acoaxial relationship relative to a cylindrical tube or wire with whichthe PSD is to be used. Also disposed within the sheath or barrel 76 is atubular pusher 82 which extends into and is slidingly received withinthe bore 74 in the handle 72. Integrally molded with or otherwise formedon the exterior surface of the tubular pusher 82 near its proximal endis a gear rack 84 which is dimensioned to fit within a key-way 86extending radially outward from the bore 74. Extending inwardly from thesurface 88 of the molded handle 72 is a recess 90 having a generallycircular profile. Fitting into the recess 90 and journaled for rotationabout a pin or axis 92 is a pinion gear 94 whose teeth engage the rack84.

It is apparent from FIG. 6 that by rotating the pinion gear 94 about itsaxis 92, the pusher member 82 can be either advanced in the distaldirection or retracted therefrom. In the view of FIG. 6, the tubularpusher 82 is shown in its fully retracted position, its distal end 96being slightly proximal of the proximal end edge of the mass ofhemostatic material 82. By simply rotating the pinion 94 in acounterclockwise direction (when viewed as in FIG. 6), the pusher member82 will be advanced in the distal direction and will force thehemostatic mass 80 out from the distal end 78 of the outer sheath orbarrel 76.

FIG. 7 discloses still another embodiment of the puncture sealing deviceof the present invention. That device is indicated generally by numeral100 and it, too, is pictured without being mounted on a tubular member,such as a dilator, introducer, catheter, etc. It includes a moldedplastic handle 102 supporting an outer tubular sheath or barrel 104which projects longitudinally outward from the distal end 106 of thehandle. As with the other embodiments, there is disposed near the distalend of the barrel 104, a mass of hemostatic material 108 which ispreformed so as to be coaxially placeable about a tubular member.

Slidably received within the barrel 104 is a tubular pusher member 110,having its distal end 112 abutting or in closely spaced relationship tothe proximal end of the hemostatic mass 108. The pusher member extendsrearward into the handle 102 through a longitudinal bore 114 formedtherein. Disposed between the proximal end 116 of the tubular pusher 110and an insert 118 fitted into the proximal end 120 of the handle 102 isa compression spring 122. Projecting radially outward from the exteriorsurface of the pusher member 110 are first and second stop members 124and 126. These stop members fit into a guideway 128 formed inwardly ofthe handle from the bore 114. At the distal end of the guideway 128 is awall surface 130 which cooperates with the stop 126 to end the distalmovement of the tubular pusher 110.

An arcuate recess 132 is formed in the handle and fitted into thatrecess is a molded plastic trigger 134 which is pivoted about a pin 136to permit limited rotation thereof.

The puncture sealing device 100 is in its cocked position when thespring 122 is compressed between the insert 118 and the proximal end 116of the pusher, as illustrated. It is held in this position by theengagement of a finger projection 137 on the trigger with the stop 124.A compression spring 138 cooperating between the handle 102 and thetrigger 134 resists counterclockwise rotation of the trigger 134.However, when the surgeon pulls back on the upwardly protruding end ofthe trigger 134, it compresses the spring 138 and rotates the finger 137out of contact with the stop 124, allowing the spring 122 to move thetubular pusher 110 in the distal direction to thereby eject the mass ofhemostatic material 108 out the distal end of the tubular sheath 104.

While each of the embodiments of the invention disclosed thus far exposethe hemostatic material by ejecting same out of the distal end of atubular sheath or barrel by the action of a movable pusher member, thehemostatic material may also be exposed by holding the tubular pusherstationary and retracting the outer barrel or sheath in a proximaldirection. In this regard, reference is made to FIG. 9 which shows a topelevation view of a PSD device of the latter type. The device isindicated generally by numeral 158 and it is seen to include an outersheath 160 having its proximal end 162 attached to a hub 164. This hubis surrounded by a rotatable collar 166 having an integrally formed knob168 thereon to facilitate its rotation. The collar 166 includes ahelical thread groove 170 in its outer surface with the knob beingjournaled for rotation on the hub 164. The hemostatic mass is identifiedby numeral 172 in FIG. 9 and it is shown as being contained within theconfines of the outer sheath 160 near its distal end 163. The distal end163 is preferably slit so as to be expansible, thereby allowing theinstrument to be used with tubular supports of differing French size.Also contained within the tubular sheath 160 is a tubular pusher 174having a lumen 176 coaxially aligned with a central bore 178 formedlongitudinally through the hemostatic mass 172. A wing-shaped fingergripmember 180 has a longitudinal bore 182 passing through it of a size toloosely surround the O.D. of the tubular sheath 160. The fingergripmember 180 is attached by means of a pin (not shown) which passesthrough the longitudinal slit 184 formed through the wall of the outertubular sheath 160.

Projecting longitudinally from the proximal side of the fingergripmember 180 is a narrow arm 186 which terminates in a radially extendingfinger 188. The finger 188 is arranged to ride in the helical groove orthread 170. It normally latches the fingergrips 180 and its attachedpusher member 174 relative to the knob 168 which is operatively coupledto the outer sleeve 160.

To deploy the hemostatic mass, the surgeon will first grip thefingergrip member 180 with his index finger and forefinger of one handwhile at the same time rotating the knob 166 in the directionrepresented by arrow 190. In doing so, the finger 188 will follow thehelical groove 170 as the hub 164 moves in the direction of arrow 192.Once the finger 188 clears the helical groove 170, the surgeon may, byholding the fingergrip stationary and retracting the knob 168 in theproximal direction, withdraw the sheath 160 from its covering relationrelative to the hemostatic mass 172. The sheath may also be formed withan averting distal end which can be made to roll back proximally toexpose the hemostatic mass surrounding the coaxially disposed tubularmember.

Moreover, it is envisioned that once the mass of hemostatic material hasbeen appropriately positioned relative to the puncture to be sealed byadvancing it within the confines of its tubular sheath, it may beexposed to blood and body fluids by providing a peel-away sheath notunlike the sheath arrangement disclosed in the U.S. Pat. No. 4,166,469to Littleford.

FIG. 10 is an enlarged view of yet another implementation of thepreferred embodiment of the present invention. It, too, includes anouter tubular sheath 200 formed from a suitable medical grade plasticand which has a somewhat bullet-shaped distal end 202 and a proximal end204 which is suitably bonded to an inner tubular hub 206 so as to movewith it. The inner hub 206 has a shoulder 208 cooperating with anannular recess formed in a rotatable knob 210. The knob 210 includesexternal threads 212 cooperating with mating thread grooves formed intothe inner cylindrical wall of an outer hub member 214.

Disposed within the lumen of the outer sheath 200 is a tubular pusher216 which is coupled to the outer hub member 214 by means of pins as at218 and 220. Positioned beyond the distal end 222 of the tubular pusher216 is a tubular mass of hemostatic material 224, preferably collagen.The diameter of the lumen 226 of the pusher member 216 and of thehemostatic mass 224 allows the assembly to fit over a further structure,such as a guidewire, an introducer, or a catheter body, all aspreviously described. The distal end of the outer sheath 200 is taperedto a reduced diameter and designed to cooperate with the O.D. of thedevice which the PSD is designed to cooperate. That is to say, the outersheath 200 is adapted to engage the O.D. of the device with which it isused at its distal end to thereby create a seal preventing the prematureingress of body fluids that might react with the collagen plug 224.

To fire the device of FIG. 10, the user grips the outer hub 214 whilerotating the knob 210 in the counterclockwise direction. As the knob 210unscrews from the outer hub 214, it retracts the inner hub 206 with itdue to the engagement of the shoulder 208 with the annular recess of theknob 210. Hence, the inner hub 206 and the sheath attached to it arealso retracted in the proximal direction. The outer sheath may be slitso that the sheath may glide past the pins 218 and 220, but preferably,the sheath is designed so that it will readily split as it is drawn overthe pins. By so designing the outer sheath, it eliminates the risk ofblood leakage through preformed slits, such as shown in the embodimentof FIG. 9.

Once the sheath 200 is retracted to the point where its distal end 202is at the proximal end 222 of the hemostatic mass 224, that mass isreleased within the puncture wound and the PSD can be removed, leavingthe hemostatic mass in place. That mass quickly reacts with blood andother body fluids to swell closed so as to act as an effective block tothe leakage or blood of the puncture wound.

OPERATION

Referring next to FIGS. 8A through 8C, the mode of use of the PSD ofFIG. 1 of the present invention will be explained. The operation and useof the other embodiments shown in FIGS. 6, 7, 9 and 10 will also bereadily understood. Prior to the stage of the procedure represented byFIG. 8A, a standard percutaneous technique of inserting an angiographicneedle into the selected blood vessel 150 has already been accomplishedand the guidewire 10 is shown as having been inserted through the needle(not shown) and gently advanced to a desired depth within the vessel.Following that, the percutaneous needle is carefully slipped off theguidewire at its proximal end while the guidewire is being held inplace. At this point, the dilator 12 will have been inserted completelyinto the lumen of the introducer 14. Following that, and in accordancewith the embodiment of FIG. 1, the dilator/introducer combination areinserted completely into the PSD indicated by numeral 32.

As is illustrated in FIGS. 8A through 8C, there is extending out fromthe hub 26 of the introducer 14 a flushing line 152, which is adapted tobe coupled via a stopcock 154, to a suitable liquid supply. At thispoint, the assembly is inverted and flushed with heparinized orunheparinized saline solution so as to remove trapped air. Once thepurge of air has been completed, the stopcock 154 is closed.

The open tip of the dilators and the accompanying introducer and PSD arenow slipped onto the proximal end of the guidewire and fed over it tothe point where the distal end of the dilator engages the blood vesselto be entered and a tactile response will be felt. The surgeon will bynow have read the depth markings on either the percutaneous needle orthe dilator and will make a mental note of same. FIG. 8A is at a stagewhere the tip of the tubular introducer 14 penetrates through the skinlayer 156. By grasping the introducer near its distal tip end and closeto the skin surface and while using a rotary motion, the dilator 12 andintroducer 14 are made to pass along the guidewire and through thetissues so that they are each positioned within the lumen of the bloodvessel as illustrated. The introducer sheath may now be further advancedto a desired position within the blood vessel.

Now, by grasping the PSD 32 near its distal tip end 42 close to the skinsurface and using a rotary motion, the PSD is advanced along theintroducer in the distal direction and through the tissue 156 until thedistal end of the PSD is tactilely determined to be up against theoutside of the vessel wall at the puncture sight. The scale markings onthe sheath can be used to measure off the distance previously noted whenthe dilator was first inserted helping to confirm the desired placementof the distal end of the sheath. See FIG. 8B.

Holding the introducer sheath and the puncture seal device in place byinstalling a suture through the suture loop 37 on the handle 30 andthrough the patient's skin or other appropriate means, the surgeon nowwithdraws the guidewire and the dilator, whereby a working catheter cannow be inserted through the lumen of the introducer and thecatheterization procedure can be completed using standard techniques.

Following the conclusion of the catheterization procedure, the surgeonwill again confirm that the position of the tip of the PSD 32 andtherefore the yet unreleased hemostatic material is up against theoutside of the vessel wall at the puncture sight. Once that has beendone, all of the devices, e.g., the working catheter and guidewire, areremoved from the introducer 14 and the locking pin 62 or other "safety"device is released. The slide 52 is advanced in the distal direction byapplying thumb pressure to the thumb pad 50 as the handle and attachedtubular sheath of the PSD are pulled back a corresponding amount. Thehemostatic mass becomes fully deployed by advancing the slide forwarduntil the mass is ejected from the split distal end of the tubularsheath 40. While compressing the tissue around the puncture sight at thetip end of the PSD and holding it in position, the introducer 14 is nowremoved from the proximal end of the PSD. After a short delay, and whilekeeping the tissue compressed around the puncture site, the PSD sheath40 is removed leaving the hemostatic seal 44 behind (FIG. 8C). Manualpressure is maintained on the puncture sight for approximately fiveminutes at which point it is relieved and an observation made as towhether the flow of blood has ceased.

The above procedure may be appropriately modified when the PSD shown inthe embodiment of FIG. 4 is employed. In particular, the guidewire,dilator and introducer sheath may be made to enter the lumen of theblood vessel before the PSD 32 of FIG. 4 is coupled onto the exteriorsurface of the tubular introducer, given the fact that the longitudinalslots 64 and 66 in the device 32 and the coaxial hemostatic mass 44allow the device to be slipped onto the introducer from the side ratherthan from the end. Those skilled in the art will also appreciate thatthe device of FIGS. 4 and 5 can be assembled onto the body of a workingcatheter already fitted into the working lumen of an endoscope and usedto deposit a plug of hemostatic material against a bleeding blood vesselwhich may be observed during the course of the endoscopic procedure.

While the embodiments illustrated in FIGS. 1, 4, 6, 7 and 9 are sizedand configured to seal a puncture wound in a blood vessel disposed arelatively short distance below the skin surface, those skilled in theart will appreciate that the dimensions of these devices may be changed,especially the lengths of the outer tubular sheath and pusher so thatthe puncture seal device may be used when carrying out any number ofsurgical procedures. For example, during the course of a laparoscopiccholecystectomy, should a blood vessel accidentally be nicked, theinstrument of the present invention may be used to stem the flow ofblood therefrom. In particular, by providing an elongated sheath orbarrel having a mass of hemostatic material near its distal end and byproviding a concentrically disposed probe, the instrument may bedirected through a laparoscope or through one of the several trocarsused in carrying out the procedure to approach the bleeder until thedistal end of the PSD is juxtaposed with it. When appropriatelypositioned, the slide mechanism or other actuator for the tubular pushercan be activated to expose at least a portion of the coaxially locatedhemostatic material from the confines of the sheath while it is beingpressed against the exterior wall of the bleeding vessel. After a fewminutes, the slide mechanism in the handle can be further actuated tototally release the mass from the distal end of the device.

It is also envisioned that the distal tip of the tubular sheath can beconfigured in a variety of ways. Specifically disclosed herein aretubular sheaths having rounded, blunt and beveled ends. It is alsocontemplated that the distal end of the tubular sheath may have aV-shaped notch formed therein, which is particularly efficacious when itis desired to have the tip end straddle the blood vessel as the sealingprocedure is performed. Still other shapes may permit a portion of thedistal end of the outer tubular sheath to physically enter the puncture,serving to stabilize the distal end of the instrument.

As an alternative to providing a suture loop 37 on the handle forfacilitating the device being locked in place by passing a suturethrough the skin and through this loop, it is also feasible to preventthe instrument of the present invention from being displaced during thecourse of a surgical procedure by providing a coarse, helicalthread-like pattern on the exterior surface of the outer tubular sheath40. When an instrument having this feature is effectively screwed intothe skin and underlying tissue to the point where a tactile sensationindicates that its distal end abuts the blood vessel to be sealed, theincreased friction afforded by the roughened surface inhibits thetendency for the instrument to slip out of the wound.

This invention has been described herein in considerable detail in orderto comply with the Patent Statutes and to provide those skilled in theart with the information needed to apply the novel principles and toconstruct and use such specialized components as are required. However,it is to be understood that the invention can be carried out byspecifically different equipment and devices, and that variousmodifications, both as to the equipment details and operatingprocedures, can be accomplished without departing from the scope of theinvention itself.

What is claimed is:
 1. A surgical delivery instrument for delivering ahemostatic substance subcutaneously against a penetration site in a wallof a blood vessel in the course of a surgical procedure in which anincision is made through the blood vessel and a tubular body with anexterior wall is passed through said incision into said blood vessel,comprising:(a) an outer tubular sheath member having a proximal end, adistal end and a lumen extending therebetween, the diameter of saidlumen being of a predetermined size greater than that of said tubularbody and adapted to allow said tubular body to pass coaxiallytherethrough; (b) a housing affixed to said proximal end of said outersheath member; (c) an annular mass of a hemostatic material, said masshaving a proximal and a distal edge surface and initially beingcontained within said outer tubular sheath member proximate said distalend thereof so as to be isolated from exposure to body fluids andadapted to coaxially surround and slide longitudinally relative to theexterior wall of said tubular body upon insertion of said tubular sheathinto said incision; (d) an inner tubular member reciprocally movablerelative to said outer tubular sheath member and within said lumen ofsaid outer tubular sheath member, said inner tubular member beingconcentrically disposed relative to said outer tubular sheath member andhaving a wall thickness for engaging said proximal edge surface of saidmass as said inner tubular member is moved relative to said outertubular sheath; and (e) a reciprocally movable slide mounted in saidhousing and operatively coupled to said inner tubular member forimparting relative movement in the longitudinal direction of said innertubular member and said outer tubular sheath for exposing said mass tobody fluids exterior of said lumen with said distal edge surface of saidannular mass against the exterior wall of said blood vessel at saidpenetration site and with no portion of said hemostatic mass or saidsurgical delivery instrument entering into said blood vessel.
 2. Thesurgical delivery instrument as in claim 1 wherein said housingcomprises:(a) a generally cylindrical tube having a wall surfacedefining a longitudinal bore with a longitudinal slot formed throughsaid wall surface into said bore; (b) said slide disposed in said bore;and (c) finger-engageable means connected to said slide and extendingthrough said slot.
 3. The surgical delivery instrument as in claim 1wherein said inner tubular member is generally rigid.
 4. The surgicaldelivery instrument as in claim 1 wherein said mass is sized to prevententry into said blood vessel through said penetration site.
 5. Thesurgical delivery instrument as in claim 1 and further including anadditional mass of said hemostatic material initially adapted tosurround said tubular body adjacently positioned relative to saidannular mass.
 6. The surgical delivery instrument as in claims 1 or 5wherein said hemostatic material is a resorbable collagen.
 7. Thesurgical delivery instrument as in claims 1 or 5 wherein said hemostaticmaterial is a resorbable gelatin.
 8. The surgical delivery instrument asin claim 1 or 5 wherein said hemostatic material is a resorbablelactide/glycoside.
 9. A surgical delivery instrument for delivering ahemostatic substance subcutaneously against a wound opening in a wall ofa blood vessel during the course of a catheterization, laparoscopic orendoscopic procedure in which an incision is made through the skin andinto said blood vessel wall, comprising:(a) a first tubular memberhaving a distal end adapted to be received into said incision; (b) anouter tubular sheath member having a proximal end, a distal end and awall surface defining a lumen extending between said proximal and distalends of said outer tubular sheath, said lumen being of a size whichallows said first tubular member to be coaxially received therein andsaid distal end of said outer tubular sheath having a generally closedbut extensible tip when said tip is subjected to an axially directedforce; (c) a housing affixed to said proximal end of said sheath member;(d) an annular shaped mass formed from a hemostatic material and havinga proximal edge surface and a distal edge surface, said mass beinginitially disposed within said sheath member in coaxial surroundingrelation relative to said first tubular member and isolated fromexposure to body fluids by said sheath member; (e) a tubular pusherreciprocally movable relative to and within said lumen of said outertubular sheath member, said pusher being concentrically disposedrelative to said outer tubular sheath member and having a wall thicknessfor engaging said proximal edge surface of said mass; (f) a reciprocallyslidable member operatively coupled between said housing and said pusherfor imparting longitudinal movement to said pusher for ejecting saidmass outward from said lumen through said extensible tip of said sheathmember along said first tubular member and against the exterior wall ofsaid blood vessel at the site of said incision and with no portion ofsaid mass and said outer tubular sheath entering said blood vessel. 10.The instrument as in claim 9 wherein said hemostatic material is a driedcollagen.
 11. The instrument as in claim 9 wherein said hemostaticmaterial is a resorbable gelatin.
 12. The instrument as in claim 9wherein said hemostatic material is a resorbable polyglycolic acid. 13.The instrument as in claim 9 wherein said housing comprises:(a) acylindrical tube having a wall surface defining a longitudinal bore witha longitudinal slot formed through said wall surface into said bore; (b)said slidable member disposed in said bore; and (c) finger-engageablemeans connected to said slidable member and extending through said slot.14. The instrument as in claim 9 wherein said pusher is sufficientlyrigid to resist longitudinal deformation when pushed against said masssufficiently hard to displace said mass from said lumen.
 15. Theinstrument as in claim 9 wherein said mass is sized to prevent passagethrough said incision in said vessel wall.
 16. The instrument as inclaim 15 wherein said mass has a rounded distal edge surface.
 17. Theinstrument as in claim 16 wherein said distal end of said tubular sheathis shaped to conform to said rounded distal edge surface of said mass.18. The instrument as in claim 17 wherein said distal end of saidtubular sheath is distensible.
 19. The instrument as in claim 15 whereinsaid mass has a blunt distal edge surface.
 20. The instrument as inclaim 9 wherein said mass has a bullet-shaped distal edge surface. 21.The instrument as in claim 15 wherein said mass has a generally beveleddistal edge surface.
 22. An instrument as in claim 15 wherein said massassumes a mushroom shape when exposed to body fluids.
 23. The instrumentas in claim 9 and further including a stop formed in said housing forlimiting movement of said pusher in the distal direction.
 24. Theinstrument as in claim 9 wherein said outer tubular sheath is providedwith means on an exterior surface for inhibiting dislodgement from awound in which said sheath is inserted.
 25. The instrument as in claim 9wherein said housing means includes means for facilitating attachment ofsaid housing to a patient's body to prevent unwanted movement of saidinstrument relative to the patient's body.
 26. A surgical deliveryinstrument for delivering a hemostatic substance subcutaneously againsta wound opening in a wall of a blood vessel during the course of acatheterization, laparoscopic or endoscopic procedure in which anincision is made through the skin and into said blood vessel wall,comprising:(a) a first tubular member having a distal end adapted to bereceived into said incision; (b) an outer tubular sheath member having aproximal end, a distal end and a wall surface defining a lumen extendingbetween said proximal and distal ends of said outer tubular sheath, saidlumen being of a size which allows said first tubular member to becoaxially received therein, said sheath member having a housingsupporting a thumb slide affixed to said proximal end thereof; (c) anannular-shaped mass formed from a hemostatic material and sized toprevent entry into said blood vessel through said incision and having aproximal edge surface and a distal edge surface, said mass beinginitially disposed within said sheath in coaxially surrounding relationrelative to said first tubular member and isolated from exposure to bodyfluids by said sheath; and (d) plunger means coaxially surrounding saidfirst tubular member and operatively coupled to said thumb slide forejecting said mass outward from said lumen at said distal end of saidsheath along said first tubular member and against the exterior wall ofsaid blood vessel at the site of said incision, said mass assuming afrusto-conical shape when exposed to body fluids.
 27. A surgicaldelivery instrument for delivering a hemostatic substance subcutaneouslyagainst a wound opening in a wall of a blood vessel during the course ofa catheterization, laparoscopic or endoscopic procedure in which anincision is made through the skin and into said blood vessel wall,comprising:(a) a first tubular member having a distal end adapted to bereceived into said incision; (b) an outer tubular sheath member having aproximal end, a distal end and a wall surface defining a lumen extendingbetween said proximal and distal ends of said outer tubular sheath, saidlumen being of a size which allows said first tubular member to becoaxially received therein, said sheath member having a housing affixedto said proximal end, said housing including a reciprocally slidablemember; (c) an annular shaped mass formed from a hemostatic material andhaving a proximal edge surface and a distal edge surface, said massbeing initially disposed within said sheath in coaxial surroundingrelation relative to said first tubular member; (d) a tubular pusherreciprocally moveable relative to and within said lumen of said outertubular sheath member, said tubular pusher being operatively coupled tosaid reciprocally slidable member in said housing, said pusher beingconcentrically disposed relative to said outer tubular sheath member andhaving a wall thickness for engaging said proximal edge surface of saidmass for ejecting said mass outward from said lumen at said distal endof said sheath along said first tubular member and against said exteriorwall of said blood vessel at the site of said incision upon displacementof said reciprocally slidable member; and (e) a releasible locking meansdisposed on said housing for preventing inadvertent deployment of saidplug.
 28. The instrument as in claim 27 wherein said housing furtherincludes first and second finger grippable segments, the first beingjoined to said pusher and the second being joined to said sheath member,and said releasable locking means comprises a pin extending between saidfirst and second segments and a hole extending through one of said firstand second segments for selectively receiving said pin therethrough. 29.A surgical delivery instrument for delivering a hemostatic substancesubcutaneously against a wound opening in a wall of a blood vesselduring the course of a catheterization, laparoscopic or endoscopicprocedure in which an incision is made through the skin and into saidblood vessel wall, comprising:(a) a first tubular member having a distalend adapted to be received into said incision; (b) an outer tubularsheath member having a proximal end, a distal end and a wall surfacedefining a lumen extending between said proximal and distal ends of saidouter tubular sheath, said lumen being of a size which allows said firsttubular member to be coaxially received therein, said sheath memberhaving a housing affixed to said proximal end, said housing including areciprocally slidable member; (c) an annular shaped mass formed from ahemostatic material and having a proximal edge surface and a distal edgesurface, said mass being initially disposed within said sheath incoaxial surrounding relation relative to said first tubular member; (d)a tubular pusher reciprocally moveable relative to and within said lumenof said outer tubular sheath member, said pusher being concentricallydisposed relative to said outer tubular sheath member and having a wallthickness for engaging said proximal edge surface of said mass forejecting said mass outward from said lumen at said distal end of saidsheath along said first tubular member and against said exterior wall ofsaid blood vessel at the site of said incision; and (e) means forreleasibly locking said housing to said pusher.
 30. A method forperforming a catheterization procedure comprising the steps of:(a) usinga hollow needle-like instrument to penetrate a selected blood vessel;(b) advancing a tubular body into the opening created by said hollowneedle-like instrument until a distal end of said tubular body entersaid blood vessel, said tubular body being coaxially disposed within apuncture sealing device and having a longitudinally displaceable mass ofa hemostatic material coaxially surrounding the exterior of said tubularbody and contained within a rigid protective sheath member of saidpuncture sealing device; (c) passing a catheter through said tubularbody into said blood vessel; (d) subsequently removing said catheterfrom said blood vessel and said tubular body; (e) using said puncturesealing device to slide said mass of hemostatic material along theexterior of said tubular body until said mass is ejected from saidprotective sheath member in a position abutting said blood vessel; and(f) removing said tubular body and said puncture sealing device, leavingsaid mass of hemostatic material in place with no portion of said massor said puncture sealing device in said blood vessel.
 31. The method asin claim 30 wherein said step of advancing said tubular bodyincludes:(a) passing a guidewire through said hollow needle-likeinstrument; (b) removing said hollow, needle-like instrument from saidguidewire; and (c) advancing said tubular body over said guidewire. 32.The method as in claim 31 and further including the step of passing adilator over said guidewire following removal of said hollow needle-likeinstrument and prior to advancing of said tubular body.
 33. A method foreffecting hemostasis of a bleeding blood vessel during the course of asurgical procedure comprising the steps of:(a) providing a puncture sealdevice having an elongated tubular outer sheath coaxially surrounding atubular pusher member and a mass of hemostatic material disposeddistally and coaxially of said pusher member, said tubular pusher memberand said mass coaxially surrounding a dilator, said dilator and saidouter sheath having corresponding fiducial marks on a surface thereoffor providing a visual indication of depth of penetration; (b)surgically creating an opening through the skin and through a selectedunderlying blood vessel; (c) advancing said puncture seal device intosaid opening until a tactile response indicates that said dilator isengaging said blood vessel; (d) noting the depth of penetration of saiddilator by observing said fiducial markings thereon at the point of theengagement; (e) performing the surgical procedure; (f) advancing saidpuncture seal device until the depth of penetration of said outer sheathreflected by said fiducial marks thereon corresponds to the noted depthof penetration of said dilator and (g) releasing said mass of hemostaticmaterial against the exterior of said blood vessel at the openingtherein.